A nurse is providing care to multiple clients on the postpartum unit.
Which of the following clients is at the greatest risk for developing a puerperal infection?
A client who has a cesarean incision that is well-approximated with no drainage.
A client who does not wash her hands between perineal care and breastfeeding.
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration.
A client who is not breastfeeding and is using measures to suppress lactation.
The Correct Answer is C
Choice A rationale
A client who has a cesarean incision that is well-approximated with no drainage is not at the greatest risk for developing a puerperal infection. While any surgical incision can potentially become infected, if the incision is healing well with no signs of infection, the risk is relatively low.
Choice B rationale
A client who does not wash her hands between perineal care and breastfeeding is increasing her risk of infection, but this is not the greatest risk factor for developing a puerperal infection. Good hand hygiene is important to prevent the spread of germs, but other factors pose a greater risk for puerperal infection.
Choice C rationale
A client who has an episiotomy that is erythematous and has extended into a third-degree laceration is at the greatest risk for developing a puerperal infection. An episiotomy is a surgical cut made at the opening of the vagina during childbirth to aid a difficult delivery and prevent rupture of tissues. If the episiotomy extends and becomes a third-degree laceration, it involves the vaginal tissue, perineal skin, and the muscle of the perineum, and can extend into the anal sphincter, the muscle that surrounds the anus. This type of wound provides a medium for bacterial growth, increasing the risk of infection.
Choice D rationale
A client who is not breastfeeding and is using measures to suppress lactation is not at the greatest risk for developing a puerperal infection. While breastfeeding can help reduce the risk of certain types of infections, not breastfeeding does not significantly increase the risk of puerperal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is characterized by high blood pressure that develops after 20 weeks of pregnancy and typically resolves within a few weeks postpartum. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of kidney damage.
However, Sarah’s condition does not fit this description because her blood pressure has been consistently high since she was 26, not just during pregnancy.
Choice B rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. Given Sarah’s history of consistent high blood pressure since age 26 and her recent seizure at 32 weeks’ gestation, this choice fits her condition.
Choice C rationale
Gestational hypertension refers to high blood pressure that begins during pregnancy. Eclampsia is a severe form of preeclampsia that causes seizures. However, Sarah’s high blood pressure did not begin during pregnancy, making this choice incorrect.
Choice D rationale
Chronic hypertension refers to high blood pressure before pregnancy or early in pregnancy. HELLP Syndrome (Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels) is a serious health condition that can affect pregnant women3. However, Sarah’s symptoms do not indicate HELLP Syndrome, making this choice incorrect.
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